Perinatal Consent Form

Next of Kin Details

GP Details

Mobile: (as provided above)

Call

Leave Voicemail

Text Message

Home Telephone: (as provided above)

Call

Leave Voicemail

Post correspondence to my above address: *

Yes - Post correspondence to my above address:

No - Post correspondence to my above address:

Send correspondence to my above email address: *

Yes - Send correspondence to my above email address:

No - Send correspondence to my above email address:

I agree that information can be shared with:

Other Mental Health Professionals: *

Yes - Other Mental Health Professionals:

No - Other Mental Health Professionals:

Acute Hospitals: *

Yes - Acute Hospitals:

No - Acute Hospitals:

Social Services: *

Yes - Social Services:

No - Social Services:

Family Members: *

Yes - Family Members:

No - Family Members:

Next of kin (as above): *

Yes - Next of kin (as above):

No - Next of kin (as above):

Other Agencies: *

Yes - Other Agencies:

No - Other Agencies:

All correspondence from the Specialist Perinatal Mental Health Service is shared with Midwifery/Health Visiting Teams as part of your wider Perinatal care team. If you do not wish for your information to be shared, please indicate by ticking the opt out box below:

Your Perinatal Care Plan will be shared with your GP as standard.

For more information on how we process and may share your data, please visit our privacy notice here: https://sussexpartnership.nhs.uk/how-we-use-your-information

We ask you for the information below to ensure we provide an equitable service to all our service users regardless of background and beliefs.

You do not have to provide this information if you do not wish to. Leave blank any sections you do not wish to complete.

Are you an ex-member of the British Armed Forces?

Yes - Are you an ex-member of the British Armed Forces?

No - Are you an ex-member of the British Armed Forces?

Do you depend on an ex-member of the British Armed Forces?

Yes - Do you depend on an ex-member of the British Armed Forces?

No - Do you depend on an ex-member of the British Armed Forces?

Do you consider yourself to have a Disability?

Yes - Do you consider yourself to have a Disability?

No - Do you consider yourself to have a Disability?

Do you or have you ever considered yourself to be Transgender?

Yes - Do you or have you ever considered yourself to be Transgender?

No - Do you or have you ever considered yourself to be Transgender?